The aim of this paper was to review current end of life (EOL) practice in Italy. The authors have made an appraisal of the existing literature in order to understand current end of life care practice in Italy. This manuscript focuses on analyzing the dying process, the transoceanic similarities and differences in the end of life decision-making practice, and the family involvement. The authors acknowledge the importance of the recent Englaro court case verdict on current practice in Italy. Dying has changed as a process over the last century in term of causes of death, costs, communication of the prognosis, and needs of the patient’s family. Regardless of national and international guidelines, there is no agreement among Italian doctors regarding the gold standards of daily clinical practice at the EOL.